=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114742343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUBLE ZERO LLC NEW GRACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2024
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1507 LEBANON ST SE
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-581-8452
-----------------------------------------------------
Fax | 360-359-7722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 LEBANON ST SE
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-581-8452
-----------------------------------------------------
Fax | 360-359-7722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | EMMALINE WANJIKU NJOROGE
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 206-581-8452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------